What is the initial management of asthma in pediatric patients in a primary care setting?

Initial Management of Pediatric Asthma in Primary Care

Begin with a short-acting beta-agonist (SABA) as rescue therapy for all children with asthma, and initiate daily low-dose inhaled corticosteroids (ICS) as first-line controller therapy for any child with persistent asthma symptoms. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by identifying key clinical features 1:

• Family history of asthma or atopy 1
• Repeated wheeze or recurrent cough, especially nocturnal 1
• Symptom triggers including viral infections, exercise, emotional disturbances, allergens (feathers, pets, pollens, dust), and cigarette smoke 1
• Age considerations: 50% of children with asthma develop symptoms by age 3, and 80% by age 5 1

Common pitfall: Childhood asthma remains underdiagnosed and undertreated, particularly in younger children. 1, 2 Not all wheezing in young children is asthma—viral respiratory infections are the most common cause in preschool-aged children. 2

Initial Controller Therapy by Age Group

Children Under 5 Years

Initiate low-dose ICS via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask as first-line therapy. 2

• Alternative options (not preferred): Leukotriene receptor antagonists (montelukast) or cromolyn sodium 2
• Dosing for montelukast: FDA-approved for chronic asthma maintenance 3
• Step-up for inadequate control: Either add long-acting beta-agonist (LABA) to low-dose ICS, or increase to medium-dose ICS (preferred in this age group for reducing exacerbations) 2

Children 5-11 Years

Initiate low-dose ICS as first-line controller therapy. 2

• Alternative options: Montelukast, cromolyn/nedocromil, or sustained-release theophylline 2
• Peak flow monitoring: Teach children ≥5 years and families how to use peak expiratory flow (PEF) measurements to adjust medications 1
• Step-up options: Add LABA (for children ≥4 years), increase ICS dose, or add leukotriene receptor antagonist 2

Children 12 Years and Older

Initiate daily low-dose ICS with as-needed SABA, or as-needed ICS and SABA used concomitantly. 2

• For moderate-to-severe persistent asthma: ICS-formoterol in a single inhaler as both daily controller and reliever therapy 2

Environmental Control and Trigger Management

Address maternal smoking as the most important modifiable environmental trigger—general practitioners are ideally positioned to observe and modify this. 1

• Allergy identification: Use specific IgE measurements and skin prick tests 1
• Avoid ineffective interventions: Acaricides show little clinical benefit 1

Goals of Asthma Control

Target the following outcomes to reduce morbidity and improve quality of life 1:

• Minimal (ideally no) chronic symptoms, including nocturnal symptoms 1
• Minimal exacerbations 1
• Minimal need for rescue bronchodilators 1
• No activity limitations, including exercise 1
• PEF ≥80% of predicted or best, with circadian variation <20% 1
• Minimal adverse effects from medications 1

Patient and Family Education

Provide both oral and written instructions covering 1:

• Proper inhaler technique (verify and document) 1
• When and how to adjust medications based on symptoms or PEF recordings 1
• Written action plan (e.g., National Asthma Campaign card format) 1
• When to call for help 1
• Spacer technique: When using large volume spacers with MDI, actuate once, breathe in that puff, then repeat for each additional puff 1

Monitoring and Follow-Up

Assess response to therapy within 4-6 weeks; consider alternative therapies or diagnoses if no clear benefit is observed. 2

Track these parameters at each visit 1:

• Days missed from school due to asthma 1
• Daytime and nighttime cough frequency 1
• Rescue medication use 1
• Activity limitation and wheeze 1
• Height and weight velocities (document to monitor for growth suppression) 1

Once control is established and sustained, attempt careful step-down in therapy. 2

What NOT to Do

Avoid these ineffective or harmful interventions 1:

• Antibiotics have no place in uncomplicated asthma management 1
• Antihistamines (including ketotifen) have proven disappointing in clinical practice 1
• Hyposensitization (immunotherapy) is not indicated for asthma management 1 (Note: Subcutaneous immunotherapy may be considered as adjunct in children ≥5 years with controlled allergic asthma 2)
• Immunosuppressive drugs (cyclosporin, methotrexate) have no clear role in routine treatment 1

Safety Considerations

ICS at recommended doses do not cause clinically significant long-term effects on growth, bone mineral density, ocular toxicity, or adrenal/pituitary suppression when followed for up to 6 years. 2 However, titrate to the lowest effective dose to maintain control while minimizing potential side effects. 2

Growth monitoring: Some evidence suggests intermittent ICS (budesonide, beclomethasone) may be associated with slightly greater growth (0.41 cm) compared to daily treatment, though daily ICS provides superior asthma control. 4

Acute Exacerbations

For acute severe asthma (too breathless to talk/feed, respiratory rate >50/min, heart rate >140/min, PEF <50% predicted) 1, 5:

• High-flow oxygen (40-60%) via face mask, target SpO₂ >92% 1, 5
• Nebulized beta-agonist: Salbutamol 5 mg or terbutaline 10 mg (half doses in very young children) 1
• Systemic corticosteroids: Prednisolone 1-2 mg/kg body weight (maximum 40 mg) for 1-5 days; no tapering needed 1, 5
• Add ipratropium 100 mcg nebulized every 6 hours if life-threatening features present 1

Critical point: In severe acute asthma, oral prednisone is superior to inhaled corticosteroids—children treated with oral prednisone had significantly better FEV₁ improvement (18.9% vs 9.4%) and lower hospitalization rates (10% vs 31%) compared to inhaled fluticasone. 6